Respiratory Flashcards

Question

Pneumonia HAP time frame?

Answer 1

Develops > 48 hrs after admission and within 2 weeks of discharge

Answer 2

- Sputum culture - Bloods - raised inflammatory markers, U&Es for urea for CURB65 - ABG if low sats/COPD - CXR - consolidation - Atypicals antigen testing

Answer 3

``` Confusion (< 8/10) Urea > 7mmol/L R: RR > 30 B: BP < 90mmHg systolic or 60 mmHg diastolic 65: > 65 yrs ``` 0-1: Home treatment 1-2: Hospital treatment 3+: Consider intensive care

Answer 4

Mild: - 5 day course of PO Amoxicillin (or macrolide) Mod-Sev: - 7-10 day course of dual Abx therapy - Amoxicillin and a macrolide Repeat CXR at 6 weeks

Answer 5

- Sepsis - Pleural effusion - Empyema - Lung abscess - Death

Answer 6

- 80% of pneumonia cases - High fever, rapid onset - Herpes labialis (cold sores!)

Answer 7

- Particularly common in COPD patients

Answer 8

- Often in patients with influenza infection or CF

Answer 9

- Atypical - Dry cough, atypical chest signs/XR findings - Autoimmune haemolytic anaemia - Erythema multiforme

Answer 10

- Atypical pneumonia - Hyponatraemia - Lymphopenia - Air conditioning units (recent cheap holiday)

Answer 11

- Classically in alcoholics

Answer 12

- FUNGAL - HIV - Dry cough - Exercise-induced desaturations - Absence of chest signs - Treat with co-trimoxazole (Trimethoprim and sulfamethoxazole)

Answer 13

- Tachypnoea - Chest pain - typically pleuritic - Dyspnoea - Haemoptysis - Tachycardia - May have fever Resp exam: - Clear chest or crackles

Answer 14

- Immbolity - Long haul flihgts - Recent surgery - Pregnancy - Hormone therapy with oestrogen - Malignancy - Polycythaemia - SLE - Thrombophilia

Answer 15

All must be negative to rule out PE - Age > 50 - HR > 100 - O2 sats < 94% - Previous DVT or PE - Recent surgery or trauma in past 4 weeks - Haemoptysis - Unilateral leg swelling - Oestrogen use (e.g. HRT, contraceptives)

Answer 16

- Clinical signs and symptoms of DVT (3) - Alternative diagnosis is less likely (3) - HR > 100 bpm (1.5) - Immobilisation for > 3 days or surgery in past 4 weeks (1.5) - Previous DVT/PE (1.5) - Haemoptysis (1) - Malignancy (on treatment, treated in last 6 months, or palliative) (1)

Answer 17

If PE likely (> 4 Wells): - CTPA - Anticoagulation in the meantime (DOAC) - if negative --> proximal leg vein USS if DVT suspected If PE unlikely (< 4 Wells): - D-Dimer - If positive --> CTPA - If negative --> PE unlikely, stop any anticoagulation Renal impairment --> use V/Q scan instead of CTPA

Answer 18

- ECG: S1Q3T3 - CXR: typically normal, use to rule out other pathology - ABG: sometimes respiratory alkalosis with low pO2

Answer 19

- Anticoagulation with DOAC (unless renal impairment or antiphospholipid syndrome --> LMWH) - Provoked vs unprovoked: 3 months for provoked, 6 months for unprovoked, 6 months for active cancer - If haemodynamically unstable--> Thrombolysis (e.g. alteplase) - If repeat PEs despite adequate anticoagulation --> consider IVC filter

Answer 20

- Mycobacterium tuberculosis: rod-shaped, acid-fast bacilli - Macrophages engulf the TB bacteria but TB bacteria secretes enzymes to inhibit its own breakdown -> encapsulated within macrophage -> proliferates -> caseous necrosis -> Gohn Focus - Gohn Focus + hilar lymph nodes = Gohn Complex Can stay like this as latent TB, then may reactivate if immunocompromised or in older age

Answer 21

- Primary: Gohn complex etc - Secondary: reactivation, mostly in apex, cavitating lesions - Systemic miliary TB - spread via vascular system to other areas of the body

Answer 22

- CNS (Tb meningitis) - Vertebral bodies (Pott's disease) - Cervical lymph nodes (scrofuloderma) - Cold abscesses - usually on the neck - Renal (sterile pyuria, WBCs in urine) - Adrenal glands (Addisons) - Liver (hepatitis) - Cutaneous TB

Answer 23

- Fever - Night sweats - Weight loss - Haemoptysis

Answer 24

CXR - Primary TB: patchy consolidation, pleural effusions, bilateral hilar lymphadenopathy - Reactivated TB: patchy or nodular consolidation with upper lobe cavitation - Disseminated miliary TB: millet seeds appearance Sputum smear - 3 specimen - Use hypertonic saline or bronchoscopy with lavage if not producing sputum - Ziehl Neelson stain -> red on blue background - Done on Lowenstein-Jensen growth medium Sputum culture - Gold-standard - Can assess drug sensitivities - Can take 1-3 weeks

Answer 25

- Intradermal infection of live attenuated TB - Do Mantoux test prior to the vaccine - only give if negative - Assess for immunosuppression/HIV - Offer to high risk: - Neonates born in areas with high rates, with relatives from countries with high rates, Fx - Unvaccinated children/young adults (<35yrs) with close contact - Unvaccinated children/young adults who have recently arrived from high risk country - Healthcare workers

Answer 26

Initial 2 months: - Rifampicin - Isoniazid - Pyrazinamide - Ethambutol Further 4 months: - Rifampicin - Isoniazid PLUS Pyridoxine (Vit B6) for full 6 months

Answer 27

- Red and orange urine - Hepatitis - Liver enzyme inducer

Answer 28

- Peripheral neuropathy (Vit B6 helps) - Hepatitis - Liver enzyme inhibitor - Agranulocytosis

Answer 29

- Hyperuricaemia -> gout - Arthralgia and myalgia - Hepatitis

Answer 30

- Difficulty recognizing colours | - Check visual acuity before and during treatment

Answer 31

- Prolonged period of 12 months of treatment | - PLUS steroids

Answer 32

- Directly observed therapy - 3 times a week - For those in certain groups, e.g. homeless people with active TB, likely to have poor concordance, all prisoners with active or latent TB

Answer 33

- Silicosis - Chronic renal failure - HIV - Solid organ transplantation with immuosuppression - IVDU - Anti-TNF treatment - Previous gastrectomy - Older age

Answer 34

Mantoux test - Purified protein derivative (PPD) - tuberculin - Injected intradermally - Result read 3 days later - Positive = had TB infection at some point - False negative may be seen in miliary TB, sarcoidosis, HIV, lymphoma, very young age (< 6 months) Interferon-gamma blood test - Looks for evidence of previous TB infection - Used in mantoux positive or equivocal, people where tuberculin test may be falsely negative - If has BCG, does not show positive (a bonus) If either are positive -> CXR to look for active infection

Answer 35

- 3 months or 'RI' (+ pyridoxine) OR - 6 months of Isoniazid (+pyridoxine)

Answer 36

- Reduced FEV1 < 80% - Reduced FVC <80% - Normal FEV1/FVC ratio >0.7/75% - Reduced TLCO

Answer 37

- Reduced FEV1 < 80% - Reduced FVC (but to a lesser extent than FEV1) - Reduced FEV1/FVC ratio <0.7/75%

Answer 38

- FEV1: forced expiratory volume - volume that has been exhaled at the end of the first second of forced expiration - FVC: forced vital capacity - volume that has been exhaled after a maximal expiration following a full inspiration

Answer 39

- Obstructive: more gradual upwards trajectory, less flat | - Restrictive: same shape of trajectory but lower on the graph

Answer 40

Umbrella term to describe conditions affecting the lung parenchyma Fibrosis --> replacement of normal elastic and functional lung tissue with scar tissue that is stiff and does not function as effectively

Answer 41

CHARTS ``` Coal workers pneumonia Histiocytosis/Hypersensitivity pneumonitis Ankylosing spondylitis Radiation Tuberculosis Silicosis/sarcoidosis ```

Answer 42

ICDA Idiopathic pulmonary fibrosis Connective tissue disorders, e.g. SLE Drug-induced: amiodarone, bleomycin, methotrexate Asbestosis

Answer 43

- CXR: ground glass changes | - Lung biopsy

Answer 44

- Remove/treat the underlying cause - Home oxygen is hypoxic at rest - Stop smoking - Physio and pulmonary rehabilitation - Flu and pneumococcal vaccines - Advanced care planning - Lung transplant - weigh up risks vs benefits

Answer 45

- 50 - 70 yrs | - Twice as common in men

Answer 46

- Insidious onset of SOB, dry cough > 3 months | - Bibasal fine inspiratory crackles and clubbing

Answer 47

- Spirometry: restrictive picture - Reduced TLCO - High resolution CT = needed for diagnosis - CXR Ground glass changes and honeycombing

Answer 48

- Pulmonary rehabilitation - Supplementary O2 - May need lung transplant eventually - Pirfenidone or Nintedanib may be used

Answer 49

- Amiodarone - Cyclophosphamide - Methotrexate - Nitrofurantoin - Bleomycin

Answer 50

Total gas transfer! The transfer factor describes the rate at which a gas will diffuse from alveoli into blood. Carbon monoxide is used to test the rate of diffusion.

Answer 51

TLCO that is corrected for lung volume

Answer 52

- Pneumonectomy/lobectomy - Scoliosis/kyphosis - Neuromuscular weakness - Ankylosis of costovertebral joints, e.g. ankylosing spondylitis

Answer 53

- Asthma - Pulmonary haemorrhage (Wegener's, Goodpasture's) - L->R cardiac shunts - Polycythaemia - Hyperkinetic states - Male gender - Exercise

Answer 54

- Pulmonary fibrosis - Pneumonia - Pulmonary emboli - Pulmonary oedema - Emphysema - Anaemia - Low cardiac output

Answer 55

- Alpha-1 antitripsin deficiency - Rheumatoid arthritis - Systemic lupus erythematosus (SLE) - Systemic sclerosis

Answer 56

- Hypersensitivity induced lung damage due to inhaled organic particles - Largely caused by immune-complex mediate tissue damage (type III hypersensitivity)

Answer 57

- Birds fancier lungs (avian proteins from bird droppings, chlamydia psittaci) - Farmers lung (spores of saccharopolyspora rectivirgula from wet hay) - Malt workers lung (aspergillus clavatus) - Mushroom workers' lung (thermophilic actinomycetes)

Answer 58

What? - Focal area of inflammation of the lung tissue Dx: - Present similarly to pneumonia - Lung biopsy is definitive Ix Tx - Systemic corticosteroids

Answer 59

- Inhalation of asbestos - Fibrogenic to lungs - Oncogenic too - Effects usually take decades to develop

Answer 60

- Pleural plaques (benign, do not undergo malignant change, do not require follow up, occur after latent phase 20-40yrs) - Pleural thickening - Lung fibrosis - Asbestosis (severity is linked to length of exposure, latent period 15-30 yrs, lower lobe, SOB and reduced exercise tolerance) - Adenocarcinoma - Mesothelioma (malignant disease)

Answer 61

Crocidolite (blue)

Answer 62

- Progressive SOB - Chest wall pain - Pleural effusion (generally painless) - Clubbing - Weight loss - Hx of asbestos exposure in 85-90% (latent period of 30-40 years)

Answer 63

- Palliative chemo - Limited role for surgery/radiotherapy - Industrial compensation

Answer 64

Poor 8-14 months = median survival

Answer 65

< 30 g/L - Heart failure (most common transudate cause) - Hypoalbuminaemia (liver disease, nephrotic syndrome, malabsorption) - Hypothyroidism - Meig's syndrome - Kidney failure/nephrotic syndrome

Answer 66

> 30 g/L - Infection: Pneumonia (most common exudate cause), TB, subphrenic abscess - Connective tissue disease (RA, SLE) - Neoplasia (lung cancer, mesothelioma, metastases) - Pancreatitis - Pulmonary embolism - Dressler's syndrome - Yellow nail syndrome

Answer 67

If the protein level is between 25-35 g/L, Light's criteria An exudate is likely if at least one of the following criteria are met: - Pleural fluid protein divided by serum protein >0.5 - Pleural fluid LDH divided by serum LDH >0.6 - Pleural fluid LDH more than two-thirds the upper limits of normal serum LDH

Answer 68

- Low glucose: rheumatoid arthritis, tuberculosis - Raised amylase: pancreatitis, oesophageal perforation - Heavy blood staining: mesothelioma, pulmonary embolism, tuberculosis

Answer 69

- Dyspnoea - Non-productive cough - Chest pain - Dullness to percussion - Reduced breath sounds - Reduced chest expansion

Answer 70

- PA chest X-Ray - USS - Contrast CT - Aspiration

Answer 71

- As above, ultrasound is recommended to reduce the complication rate - A 21G needle and 50ml syringe should be used - Fluid should be sent for pH, protein, lactate dehydrogenase (LDH), cytology and microbiology

Answer 72

- Depends on the cause, e.g. HF -> diuretics, Infection -> Abx - Recurrent aspiration - Pleurodesis - Indwelling pleural catheter - Drug management to alleviate symptoms, e.g. opioids to relieve dyspnoea

Answer 73

- Blunting of the costophrenic angle - Fluid in the lung fissures - Larger effusions will have a meniscus. This is a curving upwards where it meets the chest wall and mediastinum. - Tracheal and mediastinal deviation if it is a massive effusion

Answer 74

Empyema is where there is an infected pleural effusion.

Answer 75

Suspect an empyema in a patient who has an improving pneumonia but new or ongoing fever

Answer 76

Pleural aspiration shows pus, acidic pH (pH < 7.2), low glucose and high LDH

Answer 77

Empyema is treated by chest drain to remove the pus and antibiotics

Answer 78

- Post-infective: TB, measles, pertussis, pneumonia - Cystic fibrosis - Bronchial obstruction: lung cancer/foreign body - Immune deficiency: selective IgA, hypogammaglobulinemia - Allergic bronchopulmonary aspergillosis (ABPA) - Ciliary dyskinetic syndromes: Kartagener's syndrome, Young's syndrome - Yellow nail syndrome

Answer 79

- Haemophilus influenzae (most common) - Pseudomonas aeruginosa - Klebsiella spp. - Streptococcus pneumoniae

Answer 80

- Persistent cough - Copious purulent sputum - Intermittent haemoptysis - SOB - Recurrent chest infections - Clubbing - Coarse inspiratory crepitations

Answer 81

- Sputum culture - CXR: dilated bronchi, ring/cystic shadows, tram-tracks - High resolution CT: tram-tracks, wide bronchi, signet ring signs

Answer 82

- Physical training - Postural drainage - Abx for exacerbations and long-term rotating Abx in severe cases - bronchodilators - Immunisations - Surgery in selected cases (e.g. localised disease)

Answer 83

Permanent dilatation of the airways secondary to chronic infection or inflammation

Answer 84

LTOT should be offered to patients with a pO2 of < 7.3 kPa or to those with a pO2 of 7.3 - 8 kPa and one of the following: - Secondary polycythaemia - Nocturnal hypoxaemia - Peripheral oedema - Pulmonary hypertension

Answer 85

- Not smoker - Optimised standard treatment - Continue to have exacerbations

Answer 86

- CT thorax (exclude bronchiectasis) - Sputum culture (exclude atypical infections and TB) - LFTs - ECG to exclude QT prolongation

Answer 87

- Infection - Massive blood transfusion - Trauma - Smoke inhalation - Acute pancreatitis - Cardio-pulmonary bypass

Answer 88

- Acute onset (within 1 week of known RF) - Dyspnoea - Elevated RR - Bilateral lung crackles - Low O2 sats

Answer 89

- ABG - CXR: bilateral infiltrates (pulmonary oedema) - Non-cardiogenic (pulmonary artery wedge pressure needed if doubt) - pO2/FiO2 < 40 kPa (200 mmHg)

Answer 90

- ITU - Oxygenation/ventilation to treat hypoxaemia - General organ support (e.g. vasopressors) - Tx of underlying cause - Prone positioning and muscle relaxation

Answer 91

In the step-down treatment of asthma, aim for a reduction of 25-50% in the dose of inhaled corticosteroids

Answer 92

Acute (4-8 hrs after exposure): - Dyspnoea - Dry cough - Fever Chronic (weeks-months): - Weight loss - Productive cough - Dyspnoea - Lethargy

Answer 93

- Imaging: upper/mid-zone fibrosis - Bronchoalveolar lavage: lymphocytosis - Serologic assays for specific IgGs - Blood: NO eosinophilia

Answer 94

- Avoid triggers | - Oral glucocorticoids for severe cases or failure to avoid triggers

Answer 95

- Dextrocardia or complete situs inversus - Bronchiectasis - Recurrent sinusitis - Subfertility (secondary to diminished sperm motility and defective ciliary action in the fallopian tubes)

Answer 96

- Primary ciliary dyskinesia - Dextrocardia = quiet heart sounds, small volume complexes in lateral leads - Dynein arm defect results in immotile cilia

Answer 97

SIADH - Hyponatraemia ACTH (not typical) - Hypertension - Hyperglycaemia - Hypokalaemia - Alkalosis - Muscle weakness - CUSHINGS Lambert-Eaton Syndrome

Answer 98

- Hypercalcaemia - Clubbing - Hypertrophic pulmonary osteoarthropathy (HPOA) - Hyperthyroidism due to ectopic TSH

Answer 99

- Gynaecomastia | - Hypertrophic pulmonary osteoarthropathy (HPOA)

Answer 100

RAPID onset - Dyspnoea - Chest pain - pleuritic - Sweating - Tachypnoea - Tachycardia

Answer 101

- Pre-existing lung disease (COPD/asthma/CF/lung cancer/pneumocystis pneumonia) - Connective tissue disease (Marfans/RA) - Ventilation! - Catamenial pneumothorax (related to menstruation)

Answer 102

- Primary: no underlying lung disease | - Secondary: underlying lung disease present

Answer 103

- If rim of air < 2cm and no SOB -> consider discharge - Otherwise ASPIRATION - If this fails (> 2cm still or SOB) then chest drain

Answer 104

- If > 50 yrs and rim of air > 2cm +/- SOB then CHEST DRAIN - Otherwise ASPIRATION - If < 1cm then O2 and admit for 24 hrs

Answer 105

- Less likely to recurs than spontaenous - Majority resolve with observation - Aspiration if Tx required - If COPD/ventilation, may consider a chest drain

Answer 106

- NEVER scuba dive - No travel by air for 1 week post check XR - Avoid smoking to reduce risk of further episodes

Answer 107

- Obesity - Macroglossia: acromegaly, hypothyroidism, amyloidosis - Large tonsils - Marfan's syndrome

Answer 108

- Snoring - Period of apnoea - Daytime somnolence - Compensated respiratory acidosis - HYPERTENSION

Answer 109

- Epworth sleepiness scale | - Multiple Sleep Latency Test (MSLT) - measures time to fall asleep in a dark room

Answer 110

Sleep studies (polysomnography) - Ranging from monitoring of pulse oximetry at night to full polysomnography - Full includes: EEG, respiratory airflow, thoraco-abdominal movement, snoring and pulse oximetry

Answer 111

- Weight loss - CPAP = 1st line for moderate-severe - Intra-oral devices (e.g. mandibular advancement) if CPAP not tolerated or mild OSAHS with no daytime sleepiness - DVLA should be informed if excessive daytime sleepiness

Answer 112

- Lung cancer - Pulmonary oedema - TB - PE - LRTI - Bronchiectasis - Mitral stenosis - Aspergilloma - Granulomatosis with polyangiitis - Goodpasture's syndrome

Answer 113

- Mass-like fungus ball (mycetoma) | - Colonises an existing lung cavity (e.g. secondary to malignancy, TB, CF)

Answer 114

- Usually asymptomatic - Cough - Haemoptysis

Answer 115

- CXR: round opacity | - High titres Aspergillus precipitins

Answer 116

- Self-limiting chest infection - Result of inflammation of trachea and major bronchi - Oedematous large airways and production of sputum

Answer 117

- Cough - Sore throat - Rhinorrhoea - Wheeze - Sometimes low-grade fever

Answer 118

- Hx: sputum, wheeze, breathlessness may be absent in acute bronchitis - Examination: only wheeze in acute bronchitis. In pneumonia would see dullness to percussion, creps, bronchial breathing

Answer 119

- Typically a clinical diagnosis | - CRP can guide the need for Abx

Answer 120

- Analgesia - Good fluid intake Consider Abx therapy if: - Systemically very unwell - Pre-existing co-morbidities - CRP of 20-100 (delayed prescription) or > 100 (immediately) - Doxy would be 1st line if Abx needed. NOT in children/pregnancy -> Amoxicillin.

Answer 121

- PEFR 50-75% best or predicted - Normal speech - RR < 25 - HR < 110

Answer 122

- PEFR 33-50% - Can't complete sentences - RR > 25 - HR > 110

Answer 123

- PEFR < 33% - O2 sats < 92% - Silent chest - Cyanosis - Feeble resp effort - Bradycardia - Dysrhythmia - Hypotension - Exhaustion - Confusion - Coma - NORMAL CO2 = EXHAUSTION

Answer 124

- CXR stage 2 or 3 disease AND symptomatic - Hypercalcaemia - Eye. heart and neuro involvement

Answer 125

Acute: - Erythema nodosum - Bilateral hilar lymphadenopathy - Swinging fever - Polyarthralgia Insidious: - Dyspnoea - Non-productive cough - Malaise - Weight loss Skin: - Lupus pernio Hypercalcaemia: - Macrophages inside the granulomas cause increased conversion of Vit D to 1, 25-dihydroxycholecalciferol

Answer 126

- Mutilsystem disorder | - Non-caseating granulomas

Answer 127

More common in - Young adults - African descent

Answer 128

- Suffers are eligible for compensation if they develop asbestos related health conditions (except isolated pleural plaques). - All patients that die with known exposure to asbestos need to be referred to the coroners.

Answer 129

- Malignancy of mesothelial cells of pleura - Metastases to contralateral lung and peritoneum - Right lung affected more often than left

Answer 130

- CXR: pleural effusions or pleural thickening If pleural effusion -> send for MC&S, biochemistry and cytology - Pleural CT - Local anaesthetic thoracoscopy - Image-guided pleural biopsy if pleural nodularity seen on CT

Answer 131

- Increased resistance and pressure of blood in pulmonary arteries - Causes strain on the right side of the heart - Back pressure of blood into systemic venous system

Answer 132

5 groups - Group 1: Primary pulmonary hypertension or connective tissue disease (e.g. SLE) - Group 2: LHF - usually due to MI/systemic HTN - Group 3: Chronic lung disease (e.g. COPD) - Group 4: Pulmonary vascular diseases (e.g. PE) - Group 5: Misc, e,g, sarcoidosis, glycogen storage disease, haematological disorders

Answer 133

- SOB - Syncope - Raised JVP - Hepatomegaly - Peripheral oedema

Answer 134

- ECG: RH strain - R ventricular hypertrophy, right axis deviation, RBBB - CXR: Dilated pulmonary arteries, right ventricular hypertrophy - Others: Raised NT-proBNP (RVF), Echo to estimate pulmonary artery pressure

Answer 135

Primary: - IV prostanoids (e.g. epoprostenol) - Endothelin receptor antagonists (e.g. macitentan) - Phosphodiesterase-5-inhibitors (e.g. sildenafil) Secondary: - Treat underlying cause Supportive treatment for resp failure, arrhythmias, HF

Answer 136

- More common in men - Bimodal age distribution (20-30 yrs and 60-70 yrs) - Associated with HLA DR2

Answer 137

- Pulmonary haemorrhage | - Rapidly progressive glomerulonephritis

Answer 138

- Renal biopsy: linear IgG deposits along basement membrane, crescentic glomerulonephritis - Raised transfer factor, secondary to pulmonary haemorrhages - Anti-GBM antibodies

Answer 139

- Plasma exchange (plasmapheresis) - Steroids - Cyclophophamide

Answer 140

- Smoking - Lower respiratory tract infection - Pulmonary oedema - Inhalation of hydrocarbons - Young males

Answer 141

- URT: epistaxis, sinusitis, nasal crusting - LRT: dyspnoea, haemoptysis - Rapidly progressive glomerulonephritis - Saddle-shaped nose - Vasculitis rash - Eye involvement - Cranial nerve lesions

Answer 142

- Renal biopsy: epithelial crescents in Bowman's capsule - CXR: cavitating lesions - cANCA (90%) - pANCA (25%)

Answer 143

- Progressively worsening SOB - Use of accessory muscles - Tachypnoea - Symmetrical expiratory wheeze on auscultation - Tight chest, reduced air entry

Answer 144

- High CO2 (respiratory acidosis) | - Mechanical ventilation requirement

Answer 145

O SHIT ME ``` O: Oxygen S: Salbutamol nebs H: Hydrocortisone/Pred for 5 days I: Ipratropium bromide nebs T: Theophylline/aminophylline (severe) M: Magnesium sulphate (LT) E: Escalate - HDU/ITU/intubation (LT) ```

Answer 146

- Respiratory rate - Respiratory effort - Peak flow - Oxygen saturations - Chest auscultation - Monitor serum potassium when on salbutamol

Answer 147

- Life-threatening acute attack - Severe and not responding to initial treatment - Previous near-fatal asthma attack

Answer 148

- Been stable on their discharge medication (i.e. no nebulizers or oxygen) for **12–24 hours** - **Inhaler technique** checked and recorded - Check compliance with meds - **PEF >75%** of best or predicted - Asthma action plan and possible rescue pack - Referral to a respiratory specialist if > 2 attacks in 12 months

Answer 149

- Causes episodic exacerbations of bronchoconstriction - A reversible airway obstruction - Responds to bronchodilators, e.g. Salbutamol - Caused by Type I hypersensitivity

Answer 150

- Infection - Night time or early morning - Exercise - Animals - Cold/damp - Dust - Strong emotions

Answer 151

- Personal/family Hx of atopy - Antenatal factors: maternal smoking, viral infection during pregnancy (especially RSV) - Low birth weight - Not being breastfed - Maternal smoking - Exposure to high concentrations of allergens (e.g. house dust mite) - Air pollution - Hygiene hypothesis - Occupation

Answer 152

- Episodic symptoms - Diurnal variability, typically **worse at night** - Dry cough with wheeze and SOB - Hx of atopic conditions, such as eczema, hayfever and food allergies - Family Hx - Bilateral widespread expiratory polyphonic wheeze - A number of patients with asthma are sensitive to aspirin. Patients who are most sensitive to asthma often suffer from nasal polyps (Samter's triad).

Answer 153

- Wheeze related to coughs and colds more suggestive of viral induced wheeze - Isolated or productive cough - Normal investigations - No response to treatment - Unilateral wheeze → suggests focal lesion of infection

Answer 154

- 1st line = spirometry with bronchodilator reversibility and FeNO Spirometry: - Reduced FEV1, normal FVC, FEV1/FVC < 70% Reversibility: - FEV1 improve by 12% or increase in volume by 200 ml FeNO: - > 40 parts per billion Peak expiratory flow variability > 20%

Answer 155

1. SABA 2. ICS 3. LABA or Montelukast 4. The one that wasn't added preivously 5. Maintenance and reliever therapy (MART): ICS and LABA combined

Answer 156

- Consider stepping down treatment every 3 months or so | - When reducing inhaled steroids, do this by 25-50% at a time

Answer 157

- Individual asthma self-management programme - Yearly flu jab - Yearly asthma review - Advise exercise and avoid smoking

Answer 158

- Isocyanates (spray painting/foam moulding) - Platinum salts - Soldering flux resin - Glutaraldehyde - Flour - Epoxy resins - Proteolytic enzymes

Answer 159

- Serial peak flows when at work and away from work

Answer 160

Referral to resp specialist

Answer 161

- Fibrosing lung disease caused by the inhalation of fine particles of crystalline silicon dioxide (silica) - It is a risk factor for developing TB (silica is toxic to macrophages)

Answer 162

- Mining - Slate works - Foundries - Potteries

Answer 163

- Fibrosing lung disease | - 'Egg-shell' calcification of hilar lymph nodes

Answer 164

- Long term exposure to coal dust particles - Coal dust (2-5 nanometres) enters the lungs - Dust reaches terminal bronchioles and is engulfed by alveolar and interstitial macrophages - Moved by macrophages to mucociliary elevator and removed from body as mucus - In over exposure to coal dust -> system is overwhelmed -> macrophages accumulate in alveoli -> immune response -> damage to lung tissue

Answer 165

- Higher in populations with higher levels fo exposure (many coal mines) - Severity linked to length of exposure - Male (likely due to prevalence in coal mines) - Makes up 7% of all pneumoconiosis - Diagnosis usually made 15-20 yrs after initial exposure

Answer 166

- Most common type - Most are asymptomatic - Increases risk of lung disease, e.g. COPD - May lead to progressive massive fibrosis (PMF)

Answer 167

Category 1: some opacities but normal lung markings visible Category 2: large number of opacities but normal lung markings visible Category 3: large number of opacities with normal lung not visible

Answer 168

- CXR: Upper zone fibrosis - Spirometry: Restrictive pattern A normal or slightly reduced FEV1 and a reduced FVC

Answer 169

- Avoid exposure to coal dust and other resp irritants, e.g. smoking - Manage symptoms of chronic bronchitis - Patients eligible for compensation via Industrial Injuries Act

Answer 170

Pneumoconiosis = accumulation of dust in the lungs and the response of the bodily tissue to its presence, most commonly used in relation to coal workers’ pneumoconiosis.

Answer 171

- Dust exposure causes patients to develop round fibrotic masses which can be several centimeters in diameter - These are most commonly in the upper lobes. - The exact pathogenesis is not known. - Patients are often symptomatic and have both breathlessness on exertion and cough, some may have black sputum. - Lung function testing shows a mixed obstructive/restrictive picture.

Answer 172

- Raised respiratory rate - Use of accessory muscles of breathing, such as the sternocleidomastoid, abdominal and intercostal muscles - Intercostal and subcostal recessions - Nasal flaring - Head bobbing - Tracheal tugging - Cyanosis (due to low oxygen saturation) - Abnormal airway noises

Answer 173

- < 1 year, peak 3-6 months | - Very common in winter

Answer 174

- Congenital heart problems - Downs syndrome - CF - Bronchopulmonary dysplasia (premature) - Dual infection with metapneumovirus

Answer 175

- **RSV (75-80%)** - Mycoplasma - Adenoviruses

Answer 176

- Coryzal symptom preceding - Dry cough - Wheeze - Respiratory distress signs - Fine end-inspiratory crackles - SOB - Feeding difficulties (children) - Mild fever - Apnoeas - Tachypnoea

Answer 177

- If Downs/congenital heart disease/CF etc - < 3 months - RR > 70 bpm, head bobbing, grunting, recessions - Child looks seriously unwell to HCP - Apnoea - SpO2 < 92% - Central cyanosis

Answer 178

- Pulse oximetry - Viral throat swab - Nasopharyngeal secretion immunofluorescence may reveal RSV - If severe -> CXR, blood gas, FBC

Answer 179

- Most = self-limiting (peak 3-5 days) - Nasogastric feeding if cannot drink/eat - Suction if excessive secretions - Humidified O2 if sats < 92% - Maybe PEEP/CPAP - Intubation if required, monitor using cap blood gases - Poor ventilation = high CO2, falling pH - RIBAVIRIN → for immunocompromised and heart/lung conditions

Answer 180

- Palivizumab = **monoclonal antibody** that targets RSV. Given as prophylactic monthly injection to high risk babies, such as **ex-premature** and those with **congenital heart disease** - Maternal IgG can protect newborns against RSV

Answer 181

- Autosomal recessive disorders - Causes increased viscosity of secretions (e.g. lungs and pancreas) - Due to defect in cystic fibrosis transmembrane conductance regulator gene (CFTR) which codes a cAMP-regulated chloride channel - In UK - 80% are due to delta F508 on long arm of chromosome 7 - Affects 1 per 2500 births - Carrier rate is 1 in 25 - Around 5% are diagnosed after 18yrs

Answer 182

- Thick pancreatic and biliary secretions → blockage of the ducts → lack of digestive enzymes such as pancreatic lipase in the digestive tract - Low volume thick airway secretions → reduce airway clearance → bacterial colonisation and susceptibility to airway infections - Congenital bilateral absence of the vas deferens in males. Patients generally have healthy sperm, but the sperm have no way of getting from the testes to the ejaculate, resulting in **male infertility** - **Female subfertility**

Answer 183

- S. aureus (prophylactic fluclox) - Pseudomonas aeruginosa (neb tobramycin) - Burkholderia cepacia - Aspergillus - Escherichia coli - Klebsiella pneumoniae - Haemophilus influenza

Answer 184

- Neonatal period: meconium ileus (abdo distension and vomiting), prolonged jaundice - Recurrent chest infections (40%) - Malabsorption (30%): steatorrhorea, failure to thrive - Liver disease, pancreatitis - Chronic cough - Thick sputum production - Salty taste when kissing (concentrated salt in sweat) - Delayed puberty - Rectal prolapse (due to bulky stools) - Diabetes mellitus - Short stature - Nasal polyps - Clubbing - Crackles and wheeze on auscultation - Male infertility, female subfertility

Answer 185

- Newborn blood spot test - Genetic testing for CFTR gene (amniocentesis, chorionic villous sampling) - Sweat test (> 60 mEq/L of Cl-)

Answer 186

- Malnutrition - Adrenal insufficiency - Glycogen stroage disease - Nephrogenic diabetes inspidus - Hypothyroidism, hypoparathyroidism - G6PD - Ectodermal dysplasia

Answer 187

Skin oedema, often due to hypoalbuminaemia / hypoproteinaemia secondary to pancreatic exocrine insufficiency

Answer 188

- Chest physiotherapy and postural drainage (>BD) - High calorie diet and high fat intake - Exercise - Minimise contact with each other to prevent cross infection with *Burkholderia cepacia* complex and *Pseudomonas aeruginosa* - Vitamin supplementation - Pancreatic enzyme supplements taken with meals (CREON tablets) - Bronchodilators (e.g. Salbutamol) can help treat bronchoconstriction - Nebulised DNase or hypertonic saline - Vaccinations: pneumococcal, influenza, varicella - Fertility treatment and genetic counselling Lung transplantation Lumacaftor/lvacaftor (Orkambi): - Used in CF patients who are homozygous for delta F508 mutation

Answer 189

Potentiator of CFTR that is already at cell surface, increasing the probability that the defective channel with be open and allow chloride ions to pass through the channel pore

Answer 190

Increases CFTR protein numbers that are transported to cell surface

Answer 191

Chronic infection with Burkholderia cepacia is an important CF-specific CI to lung transplantation

Answer 192

- Followed up every 6 months - Regular monitoring of sputum for colonisation - Monitoring for DM, osteoporosis, Vit D deficiency, liver failure

Answer 193

- 90% of patients with CF develop pancreatic insufficiency - 50% of adults with CF develop cystic fibrosis-related diabetes and require treatment with insulin - 30% of adults with CF develop liver disease - Most males are infertile due to absent vas deferens

Answer 194

- Anterior edge latissimus dorsi - Lateral border of pectoralis major - Line superior to the horizontal level of the nipple (5th intercostal space) - Apex below the axilla

Answer 195

4 T's - Teratoma - Terrible lymphadenopathy - Thymic mass - Thyroid mass